A combined approach for the treatment of lateral and

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A combined approach for the treatment of lateral and

Transcript Of A combined approach for the treatment of lateral and

Injury, Int. J. Care Injured 47 (2016) 2326–2330
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Injury
journal homepage: www.elsevier.com/locate/injury

A combined approach for the treatment of lateral and posterolateral tibial plateau fractures
Peng Zhanga, Kejian Liana, Deqing Luoa, Zunxian Huanga, Teng Lia, Dasheng Lina,b,*
a Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China b Experimental Surgery and Regenerative Medicine, Department of Surgery, Ludwig Maximilians University, Munich, Germany

ARTICLE INFO
Keywords: Tibial plateau fracture Lateral Posterolateral Approach

A B S T R A C T
Introduction: The treatment of tibial plateau fractures involving the lateral and posterolateral column is a demanding and fine surgical challenge. The purpose of this study was to evaluate the safety and clinical efficacy of combined approach for the treatment of lateral and posterolateral tibial plateau fractures. Methods: A prospective study was performed in 17 patients with lateral and posterolateral tibial plateau fractures between January 2009 and December 2012. There were 12 males and 5 females with a mean age of 40 years. All of them received dual-plate fixation through the combined approach, with the patients in a floating position. The combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach. Operation time, intraoperative blood loss, fracture healing time, Hospital for Special Surgery (HSS) knee score, knee flexion and extension range of motion, and complications were recorded to evaluate treatment effects. Results: There were no intraoperative complications related to this technology. Mean operation time was 144 min with a mean intraoperative blood loss volume of 233 mL. The mean follow-up was 23 months. All 17 patients had good postoperative fracture healing. Mean union time was 12 weeks. At the final followup, the average HSS score was 92.5, with the average knee flexion of 125 and an average knee extension of 2. Two patients had complications in postoperative incisions with aseptic fat liquefaction. After thorough debridement, second-stage wounds healing were achieved. No neurovascular injury occurred. No collapse of reduced articular surface was detected. Conclusions: The combined approach with dual-plate offers direct and complete surgical exposure and provide an effective method for the treatment of lateral and posterolateral tibial plateau fractures.
ã 2016 Elsevier Ltd. All rights reserved.

Introduction
Tibial plateau fractures are commonly encountered in clinical practice, whereas posterolateral tibial plateau fracture is rarely reported in the past, with an incidence of 7% [1]. This posterolateral fracture has the following features: the mainly displaced fragment is located at the posterior half of the lateral condyle and/or a fracture line impacts the posterior aspect of the lateral plateau [2]. Most of the current classification systems for tibial plateau fractures are the AO/OTA and Schatzker classifications, which established on the basis of anteroposterior radiographs of the proximal tibia, two-dimensional superimposed images of its coronal plane. This posterolateral fracture is a special fracture pattern that is not well described by the AO/OTA or Schatzker
* Corresponding author at: Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China.
E-mail address: [email protected] (D. Lin).
http://dx.doi.org/10.1016/j.injury.2016.07.004 0020-1383/ã 2016 Elsevier Ltd. All rights reserved.

classification systems. With careful review and application of the computed tomography (CT) scan for the evaluation for these fractures, Luo et al. [3] proposed a theory of Three-column classification that the tibial plateau is divided into three columns: the medial, the lateral and the posterior, and the posterior column is subdivided into the posteromedial and posterolateral columns.
Realizing the importance of fixation in posterolateral tibial plateau fractures, various approaches have been explored to achieve reduction and fixation for posterolateral fracture [4–6]. Lobenhoffer et al. [7] described a combined approach for the treatment of posterior tibial plateau fractures, but the fibula neck needed to be osteotomized in his method. More scholars introduced a posterolateral approach without fibular head osteotomy, which favored direct reduction and placement of a posterolateral buttress plate [8–10]. However, these methods all demonstrate a trend toward using posterior approaches for this kind of fractures. Posterior column fractures of tibial plateau, especially those involving the posterolateral section, are quite difficult to manage in clinic. When lateral and posterolateral

P. Zhang et al. / Injury, Int. J. Care Injured 47 (2016) 2326–2330

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column fracture were existed simultaneously, it is more difficult to operate for orthopaedic surgeons. Thus, we have tried to use dualplate fixation through a combined approach for the treatment of lateral and posterolateral tibial plateau fractures, with the patients in a floating position. The combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach. This study aimed to evaluate the safety and clinical efficacy of this combined approach for lateral and posterolateral tibial plateau fractures.

Material and methods

We obtained institutional review board approval for this study. Between January 2009 and December 2012, 17 patients with lateral and posterolateral tibial plateau fractures were operated via the combined approach with dual-plate fixation. Patients with osteofascial compartment syndrome, pathologic fractures, autoimmune diseases, blood disorder, severe multiple trauma (Injury severity scale, ISS > 16) [11], and surgical contraindications were excluded. Anteroposterior and lateral radiographic views and three-dimensional CT reconstruction images of the tibial plateau were taken in all patients.
The patients consisted of 12 males and 5 females, with a mean age of 40 (26–54) years. The reasons for injury included 7 motor vehicle accidents, 5 falls from a height, and 5 motorcycle crashes. Five patients had associated injuries. None of the patients sustained neurovascular injury (Table 1). Preoperative management included distal bony traction and splint. All operations were performed by the same experienced trauma surgeons after the soft tissue condition was stable, which the striae appeared.
Surgical technique
All patients underwent surgery under spinal anesthesia or general anesthetic, and were operated in a lateral floating position that could facilitate combined posterior and anterior approaches by rotating the lower limb [12]. The knee was maintained in a slightly flexed position. The incision for the inverted L-shaped posterolateral approach was a composite of horizontal and vertical incisions, which was approximately 10 cm to 12 cm in length (Fig. 1). The horizontal incision began at the center of the popliteal fossa. It traversed along the crease to the outside, then turned distally and extended longitudinally along the lateral margin of the lateral head of gastrocnemius muscle. The subcutaneous tissue and popliteal fascia are incised by sharp dissection. Full-thickness

Fig. 1. The surgical approach performed.
fasciocutaneous flaps were elevated, which aimed to protect the lateral sural cutaneous nerves and common peroneal nerve. The lateral head of gastrocnemius muscle and common peroneal nerve was retracted laterally. Then the popliteal neurovascular bundle, which lies medially, were retracted medially by a Langenbeck retractor. Next, we will see the popliteal muscle and soleus. The fibular origin of the soleus is dissected along the medial border of the proximal fibula, and the tibial origin of the soleus is partially divided from lateral to medial. Precautions were taken to protect the anterior tibial vessel in the distal end of the incision. The joint capsule and posterolateral condyles of the tibial plateau were exposed between the popliteal muscle and the soleus muscle. Then the inferior border of the popliteus muscle is dissected and retracted upward, and the inferior lateral genicular vessels on the surface of the popliteus muscle are ligated only if necessary. The posterior joint capsule was incised longitudinally, and the lateral posterior horn of the meniscus was displaced upwards, so that the

Table 1 Patient characteristics.

Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Age (y) Sex Associated injury Operation time Blood loss Follow-up Healing time HSS score Knee flexion () Knee extension Complications

(min)

(mL)

(mo)

(week)

( )

31

M –

128

220

30

12

94

125

2

47

M –

143

180

15

10

96

130

0

39

F –

120

150

36

11

94

125

2

44

M Head trauma

142

220

21

12

90

120

3

47

M –

160

300

27

14

93

130

5

28

F –

157

280

15

15

87

115

0

34

F Head trauma

146

250

18

13

96

130

2

26

M –

150

220

24

12

94

125

0

48

M Humeral fracture 145

190

18

12

90

120

3

35

M –

180

200

21

13

96

130

5

37

M –

152

350

24

15

87

115

0

44

F Chest injury

160

250

27

11

90

120

3

42

M –

147

260

12

10

96

130

0

54

M Radius fracture 135

180

24

12

93

125

5

41

F –

95

200

33

10

90

120

0

43

M –

137

230

24

12

94

130

5

37

M –

150

280

21

10

93

130

0

– – – Fat liquefaction – – – – – Fat liquefaction – – – – – – –

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posterolateral condyle of the tibial plateau can be seen. Fractures involving the posterolateral column could be clearly observed. The fracture was fixed temporarily with Kirschner wires, and then a precontoured T buttress plate (3.5-mm system plates) was placed for supportive fixation.
The patients were then moved to the supine position. A traditional anterolateral approach to the proximal tibia is used. It was worth noting that the sufficient length of the minimum distance of 7 cm between the incisions was applied, which avoid ischemic necrosis of the skin bridge and wound complications. Then the lateral joint capsule and coronary ligament are incised, and the lateral meniscus is identified, so that we could retract it laterally and superiorly to aid in visualization of the joint surface. A cortical window below the area of depression was made to evaluate the articular surface and graft bone, which was obtained from the iliaccrest of the patient or the bone bank. Multiple Kirschner wires were used as a temporary fixation for the fragments if necessarily. Subchondral raft screw formation of the lateral or anterolateral plates (4.5-mm system plates for proximal tibia) was attempted [13]. Under fluoroscopic guidance, the quality of joint reduction, location of the plates, and length of the screws were confirmed. The meniscus was carefully sutured back to its attachment. Then the subcutaneous tissue and skin were closed over suction drains.
Postoperatively, a passive motion machine was used for several hours everyday and physical therapy with emphasis on muscle strengthening exercises was prescribed. Within the second postoperative week, patients began partial weight bearing. At 12 weeks after the operation, the patients were encouraged to progress to full weight bearing. Radiographs were taken monthly

in the first three postoperative months. Thereafter, patients were followed up regularly, physical examination was performed and standard X-ray radiographs were obtained at each follow-up visit. The quality of fracture reduction was evaluated on the basis of four radiographic parameters: articular reduction, tibial plateau angle (TPA), the femorotibial angle (FTA) and the medial posterior slop angle (PA). All measurements were performed by the first author. Malreduction was defined as articular step-off of !2 mm, or a TPA ! 95/TPA 80, or PA ! 15/PA À5 [14]. At the final followup, measurements of the knee range of motion were done and all the functional outcome were evaluated using the Hospital for Special Surgery (HSS) knee scoring system [15].
Results
There were no intraoperative complications related to this technology. The mean operation time was 144 (95–180) minutes with mean intraoperative blood loss volume of 233 (150–350) mL. Seventeen patients all have been followed up, and the mean time of follow-up was 23 (12–36) months. After surgery, Bony union occurred at a mean of 12 (10–15) weeks. At the final follow-up, the average HSS score was 92.5 (87–96), with the average knee flexion of 125 (115–130) and an average knee extension of 2 (0–5). All patients had a satisfactory articular reduction ( 2 mm step), with no fracture displacement or plate rupture observed. Two patients had complications in postoperative incisions with aseptic fat liquefaction. After thorough debridement, second-stage wounds healing were achieved. No neurovascular injury occurred. No collapse of reduced articular surface was detected (Table 1). The typical case is shown in Fig. 2.

Fig. 2. A 38-year-old woman had left-sided tibial plateau fractures after high energy trauma. Her preoperative anteroposterior radiograph and CT show (a–d) that the tibial plateau fractures involved lateral and posterolateral column. This case was treat with dual plates through the combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach (e–g). Follow-up anteroposterior radiograph after 1 year shows complete union of fracture (h, i). The clinical outcome was excellent.

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Discussion
When the tibial plateau fractures involve the lateral and posterolateral columns simultaneously, the barrier structures, fibular head, and common peroneal nerve make it very difficult to address the two columns fractures via a single approach [11]. Although the anterolateral approach is relatively simple and safe, but it could not entirely meet the requirements of anatomical reduction and stiff supporting fixation of posterior column fractures [12]. Yu et al. [16] described an anterolateral approach by removing partial or full head of the fibula, which they considered beneficial to reduction and fixation of posterolateral tibial plateau fractures. But it was not advisable to sacrifice important normal structures for the sake of fracture exposure and management. Frosch et al. [8] introduced a new surgical approach for posterolateral tibial plateau fractures, which involved a lateral arthrotomy for visualizing the joint surface and a posterolateral approach for the fracture reduction and plate fixation. Such an approach, providing exposure and internal fixation but at the cost of the wide range of soft tissue stripping and the exposure of the common peroneal nerve. Tao et al. [10] presented a modified posterolateral approach for posterolateral shearing tibial plateau fractures, in which an L-shaped incision was initiated at the midline point of the popliteal fossa and then curved transversely and extended distally, without necessity of osteotomy, tenotomy, or division of muscles. Then the full restoration of alignment in the proximal tibia by this approach achieved knee stability and satisfactory clinical outcome. We note that most orthopaedic surgeons used the posteromedial reversed L-shaped approach to expose posterior column [12,17–19], because it is sufficient to reduce the risk of neural injury. However, comparing to posterolateral approach to exposure of posterolateral column, it requires massive dissection of soft tissue envelope which may affect joint movement, even sometimes the exposure of posterolateral column is difficult due to the gastrocnemius-soleus muscles are too strong in some cases and it is difficult to retract them laterally.
In terms of the lateral and posterolateral tibial plateau fractures, it is considered to be a marked feature of severe and complex tibial plateau fractures, when including the lateral and posterolateral column. We used an inverted L-shaped incision, placed on the posterolateral corner of the knee, with an anterolateral approach, which achieved adequate exposures both of the lateral and posterior aspect. Advantages of the combined approach include the following: (1) patient underwent surgery in a lateral floating position that could facilitate combined posterior and anterior approaches by rotating the lower limb, and the operative time was significantly shorter than secondary surgical field draping; (2) providing sufficient operation space to avoid neurovascular injury, without fibular head resection; (3) the compression and cleavages fractures of posterolateral column can be manipulated with direct vision, which is more favorable for reduction; (4) fully using of the skin folds of the popliteal crease to reduce the tension on the incision, helping to avoid postoperative flexion contractures and dysfunction. The posterolateral exposure could not be extended distally yet. Trifurcation vessels traversing the interosseus membrane and the mass of muscle and tissue medial to the fibula make an exposure past approximately 8–10 cm distal to the lateral joint line difficult [10]. The direct posterolateral plate could be used as a buttress and plays an important role in maintaining the reduction of the posterolateral fragment. The dual-plate, a posterolateral buttress plate with an anterolateral plate, which could support the articular surface and strong enough to resist axial loading. But for other more serious tibial plateau fractures, the dual-plate is not enough to fix stably, some articles introduced multi-plate can provide more stable fixation [12,18,19].

The tibial plateau fractures result from impaction of the femoral condyle into the tibial plateau, caused by axial loading with valgus or varus forces. Because the tibial plateau is made of cancellous bone, a compression fracture usually cause bone defect. Therefore, Impaction bone grafting can promise results as an adjunct to the surgical stabilisation of tibial plateau fractures, and provide enough fracture stability for patients to mobilise weight-bearing as tolerated immediately after surgery [20]. Meanwhile, Impaction bone grafting can also avoid collapse of articular surface and promote fracture healing.
The combined approach included an anterolateral approach and an inverted L-shaped posterolateral approach, with dual-plate, offers direct and complete surgical exposure and provide an effective method for the treatment of lateral and posterolateral tibial plateau fractures. However, the current study has limitations. A prospective study with a larger number of patients would help confirm the advantages of the combined approach for the treatment of lateral and posterolateral tibial plateau fractures.
Conflict of interest statement
The authors have no conflict of interest.
Funding
No funds were received in support of this work.
Acknowledgment
We acknowledge the written consent for publication obtained from the patient featured in the manuscript.
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ApproachPatientsTreatmentTibial Plateau FracturesTibial Plateau